What is a Gate Keeper?

Many types of managed care plans use primary care
physicians as gate keepers to control costs and
coordinate health care services for their members. When
individuals join a plan, they are provided a list of
physicians who are part of the managed care network.
Members are expected to select one of the primary care
doctors on the list. Before making a final selection,
find out if the doctor is accepting new patients from
your managed care plan. Some limit the number of managed
care patients they will accept. Besides it is a good
idea to interview the doctor in order to find out if
this is someone you can work with. A primary care
provider is usually a family practitioner or a general
internist. For a woman, it might be a gynecologist. For
younger patients, a pediatrician or family practitioner
usually handles routine care.

Under some managed care plans, the member is expected
to contact their primary care provider before receiving
any health care. This is where the term gate keeper
comes from. Many plans require that the individual's
primary care doctor make a formal referral to a
specialist. If the individual makes an appointment for a
specialist without the referral, he may be responsible
for all or most of the specialist's bill.

There are some advantages to having a primary care
provider. It is estimated that 90% of an individual's
medical needs can be met by a primary care physician in
the office. Since primary care doctors typically charge
less, the cost of health care is reduced. Under ideal
conditions, the primary care provider functions much
like the traditional family doctor. He focuses on the
health of the whole person rather than on a single organ
system in the body. He emphasizes the importance of
prevention and establishes a schedule for
age-appropriate health screening. When a suspected
problem does exist, he can make the initial diagnosis,
advise the patient on further treatment and make
necessary referrals. The fact that all medical records
are kept in one location also contributes to care that
is better coordinated.

One concern about this approach is that too few
services will be provided. In order to control costs the
"gate keeper" may limit access to specialists or more
costly tests and procedures. However, most plans (at
least HMOs) are required to have a formal grievance
procedure. To insure the quality of their care, members
should become familiar with their plan's grievance
procedure, and be assertive about using such procedures
when they believe the quality of their care is
inadequate. There is another safeguard. Doctors know
that poorer health outcomes and higher costs can result
when care is not adequate or delayed. Therefore, whether
practicing in managed care networks or under
conventional insurance plans, good doctors are likely to
continue to provide quality care in a timely manner.